In addition to these
proposed changes, CMS “clarified” a number of coding requirements that has had the
industry buzzing. Included in these clarifications is a directive
to hospices that non-specific diagnoses such as Debility or Adult Failure to Thrive
(AFTT) may no longer be listed as a principle terminal diagnosis on the hospice
claim. Claims submitted with these diagnoses would be returned to the provider
(RTPd) for a more definitive hospice diagnosis. However, Debility and AFTT can
and should be listed on the claim as secondary (related) conditions to support
prognosis if indicated. CMS states that
disallowing these diagnoses is not a new position, which comes as a surprise to
most of us in the industry (otherwise why does CMS’ Medicare Administrative
Contractor (MAC), Palmetto GBA, have an LCD guideline for AFTT?).

Why is CMS making this clarification now?

According to the Proposed Rule, CMS is taking
action because of the growing number of patients admitted to hospice with these
ill-defined conditions that are inherently symptom syndromes, not actual
terminal diagnoses. This is born out by National Hospice and Palliative Care
Organization (NHPCO) statistics, listing Debility Unspecified as the leading
non-cancer diagnosis in hospice, comprising 13.9% of hospice admissions in 2011. CMS also expressed concern that individualized, patient-centered plans of care
are difficult to develop for patients with these conditions and, consequently,
the patient may not receive the full benefit of hospice services.

Many in the industry
believe that this is another way to achieve CMS’ goal of reserving the Medicare Hospice
Benefit for those who are terminally, not chronically, ill. Debility and AFTT
patients frequently have long length of stays (LOS) in hospice. Hospices
with sizeable numbers of patients with these diagnoses with a LOS greater than
180 days have been targeted for payment-related scrutiny through the additional
development request (ADR) process. CMS hoped that the Face-to-Face regulation
would identify some of these patients as no longer eligible upon
recertification and, therefore, would be discharged alive. When that didn’t
happen, they needed to come up with Plan B.

What is the impact on hospices and the patients for
whom they care?

Fortunately, some hospices
have already reduced or eliminated the use of these diagnoses as the primary
terminal diagnosis. For those hospices, there will be little impact. Those programs
still admitting and caring for patients with debility/AFTT will need to take a
number of actions to be in compliance. Below are some suggested steps that
hospices can take:

Immediately cease using
Debility or AFTT and other non-specific diagnoses as the primary diagnosis for
any new patients.

Instead of Debility or
AFTT, select a primary diagnosis that is most contributory to the patient’s
terminal disease trajectory and requires end-of-life palliative interventions.

Use other health
conditions (debility, AFTT, etc.) to support prognosis as needed. This is
especially important if the primary diagnosis does not have an LCD guideline associated
with it or if the patient’s clinical status does not meet the LCD guideline in
its entirety.

Include
debility, AFTT and all other prognosis-impacting conditions on the claims form
(just not as the primary diagnosis).

Perform a census analysis
to identify any patients that fall into the ICD 9 category of “Symptoms, Signs,
and Ill-Defined Conditions” (ICD 9 codes
780-799).

Have your Medical Director
or Hospice Team Physician review each patient’s clinical record to identify an alternate
primary diagnosis. Tips to identifying an alternate diagnosis include:

Review
the Plan of Care (POC) to determine the body system, symptoms and psychosocial/spiritual
issues that require the greatest amount of palliative interventions.

Review
the drug profile to identify what medications are being used and for what
purpose.

Ask
yourself, if the patient died tomorrow, what would the physician list as the cause
of death on the death certificate?

When changing a patient’s primary
hospice diagnosis, remember to do the following:

Obtain a physician order for the new diagnosis.

Obtain a new physician narrative that paints the
picture for eligibility for the new diagnosis that is supported by
documentation in the clinical record.

Develop a new POC based upon an updated
comprehensive assessment.

Update the drug profile with appropriate designation
of related/covered or not related/not covered.

Change billing codes.

Communicate these changes with staff members,
attending physicians, and referral sources, including nursing facilities and
assisted living facilities.

The diagnosis can be
changed on the next claim, or an adjustment may be made to a prior claim if
needed. It is not necessary to cancel any claims already processed with the
original diagnosis.

If the patient has no
clear alternate diagnosis that is supported by clinical documentation, and if the
POC has not changed over time to reflect end-of-life symptom management, it is
important that consideration is given to discharge the patient.

Please see “Tips for Hospices…” below for a
printable resource with these tips and more.

There
are patients with these ill-defined diagnoses who will no longer be deemed
eligible for hospice care. Sadly, most are elderly, frail, and slowly dying
from a myriad of conditions that do not meet today’s hospice standards. The
Hospice Medicare Benefit was never intended to care for these patients, but neither
is there a safety net for these patients and their families if access to
hospice is denied. In the end, these patients and families may be without
needed care and hospices will be burdened with the difficult job of discharging
them.